LDL cholesterol, statins, and plaque regression

The ASTEROID Trial reported in 2006 examined the effects of LDL cholesterol reduction using the statin drug, rosuvastatin (Crestor), with coronary atherosclerosis quantified and tracked with intracoronary ultrasound. The Track Your Plaque report, New study confirms: LDL of 60 mg reverses plaque, on the ASTEROID Trial provides commentary on the results.

Though I remain skeptical that a statin-only treatment strategy can reverse coronary plaque in the majority of people, I do believe that the AstraZeneca-sponsored ASTEROID Trial does add to the wisdom on heart disease management. More importantly, it has served to raise awareness among both the public and my physician colleagues that atherosclerosis is indeed a potentially reversible condition.

Specifically, the ASTEROID results confirm that, either directly or indirectly, LDL cholesterol reduction achieved with statin agents does correspond to increasing degrees of plaque reversal. The mean (calculated) LDL cholesterol achieved in ASTEROID was 60 mg/dl, the same as the Track Your Plaque suggested LDL target.

Though the ASTEROID Trial is not news, I stumbled on a chart posted on the ASTEROID Trial website that clearly highlights how a number of other studies beyond ASTEROID have fallen into this pattern:

The graph reveals a linear relationship: The greater the reduction in LDL cholesterol with statin drugs, the greater the plaque regression ("change in percent atheroma volume"). (Several other studies not included in the graph also cluster into the same linear relationship.)

I am no supporter of drug companies, nor a defender of their policies and practices. But I do believe that their data can serve to teach us a few lessons. For instance, here is an (cherry-picked, to be sure) example of intracoronary ultrasound cross-sectional images before and after two years of rosuvastatin, 40 mg daily:

The color-coded/outlined atherosclerotic coronary plaque is shown shrinking, while the "lumen," or the path for blood to flow, enlarges. The reduction in coronary plaque is irrefutable. (The small circle within the lumen with the white halo surrounding it is the ultrasound catheter.)

If you and I were to choose a single treatment approach to coronary disease reversal, then 40 mg of rosuvastatin is probably at the top of the list. However, in the Track Your Plaque program, we do not advocate a single treatment strategy. While the Crestor-only approach is relatively straightforward--one pill a day--few people, in my experience, can tolerate this dose for any length of time. Patients invariably have to stop the drug or reduce the dose severely due to muscle aches when I've had patients try it. Contrary to the ASTEROID results, in my experience the majority of people, perhaps all, eventually give up with this improbable "one-size-fits-all" scheme.

The Track Your Plaque approach, while more complicated and involves several nutritional supplements and strategies, in my view addresses more causes of coronary plaque, is better tolerated, and provides health benefits outside of just LDL cholesterol reduction. It also minimizes or eliminates the need for prescription medication.

Studies cited in graph:

1.Nissen S et al. N Engl J Med 2006;354:1253-1263.
2 Tardif J et al. Circulation 2004;110:3372-3377.
3 Nissen S et al. JAMA 2006;295 (13):1556-1565
4 Nissen S et al. JAMA 2004;292: 2217–2225.
5 Nissen S et al. JAMA 2004; 291:1071–1080

评论 (12) -

  • J Michael Nicholls

    2008/4/13 6:49:00 |

    Dear Dr. Davis,
    I have read your blog for some time now, and I consider it to be the no 1 in the nutrition-health-cardiology field. A couple of years ago I became interested in the “cholesterol theory” and I have studied the development of the statins in detail. Having a background in the “hard sciences” I am appalled at the lack of sound science in this field in particular, as well as in some other areas of medical research.

    To my knowledge there is zero evidence that the lowering of any of the cholesterol levels has anything to do with preventing heart disease or reversing plack. On the contrary, an anti-inflammatory mechanism is probably the reason for the little protective effect there is, while the lowering of the cholesterol levels probably causes more harm then good (as can be suspected from the extensive list of side effects).

    Reading this post and the statement, “LDL cholesterol reduction achieved with statin agents does correspond to increasing degrees of plaque reversal”, I couldn’t help feeling that some readers would get it all wrong, especially since “cholesterol lowering” is the healing mantra that is being communicated to the market (and even most doctors seem to advocate).

  • Anonymous

    2008/4/13 23:50:00 |

    "Having a background in the hard sciences"? In the "hard siences" they call plaque "plak" ? That was a dead give away that you have no idea what your talking about even before you made the ridiculus statement"to my knowledge there is zero eveidence that the lowering of any of the cholesterol has anything to do with preveting heart disease or lowering plak(sic)" You should read some of the studies, they're easily found on the internet or in journals. By the way did you look at the pictures Dr. davis put up in the article? As Dr. davis always says I don't work for the drug companies and statins certainly aren't miracle drugs but they do have a place. Ever hear of the Framingham Study, just a small study thats been going on for over 60 years now and has studied over 10,000 people( now in its third generation) and they have NEVER had a recorded heart attack in ANYBODY with a cholesterol level under 150. So much for "your knowledge"

  • Anonymous

    2008/4/14 4:40:00 |

    Dear Dr. Davis,

    In reading this and about vitamin D, if you have a plaque problem, but your HDL is high and your Vitamin D level in normal, would it still be helpful to take the suppliment?

  • J Michael Nicholls

    2008/4/14 13:56:00 |

    Dear Anonymous, there is no need to be so sarcastic, and I apologize for spelling plaque plack. Do you mean to say that all of medical science is of high quality, and that it shouldn’t be questioned? Most of the serious critique against the cholesterol hypothesis comes from medical researchers by the way. I am waiting to be enlightened, please show me the evidence that the LOWERING of cholesterol by it self (per se) is the protective mechanism of statins.

    From your writing it appears that you still believe in the old dogma of high cholesterol CAUSING atherosclerosis. Only a few of the fiercest statinators in the research community still maintain that, and probably so for financial reasons (most statin-advertising is doing its best to communicate just that). Most GPs seem to believe that cholesterol causes atherosclerosis too. It is trivial that in any academic context “correspond to”, “linear relationship” or “associated with” do not mean “direct effect of” or “directly caused by”. With this simple understanding we would have better doctors and better scientist in the medical field, and consequently less treatment of SYMPTOMS such as high cholesterol, high blood pressure and high blood sugar. By the way, is there any proof that atherosclerosis is not causing the higher cholesterol levels instead of the other way around?

    The problem with many defenders of the cholesterol dogma is that they don’t read the scientific literature in a scientific way. I personally don’t know of anyone still believing in the cholesterol hypothesis after having studied it in depth from strictly scientific principles. There is simply no evidence to motivate all the “lowering” of “levels”. It is nothing more than a highly profitable market concept ($30 billion in 2007).

  • Anonymous

    2008/4/14 14:25:00 |

    Great write up.

    As  a diabetic, with all of my numbers under very good control, I have been on statins for 8 years and my last two heart scans (5 years apart) had a score of 0 plague.  My question is the following:

    Are you saying that statins are good and should be part of a comprehensive approach?

    Many websites that push your blog are against the use of statins in any approach.  How do you respond to that type of thinking?

    Should you continue taking drugs to reduce your plague if your score is zero?

    Thanks for your time

  • Anonymous

    2008/4/14 18:23:00 |

    Playing devil's advocate, I'm not sure if science has proved cholesterol to be a cause of heart disease. What if it's a marker and not a cause?

    Those in the Framingham study with low cholesterol values might not get heart attacks due to lifestyle/genetics, and their low cholesterol is a reflection of their overall good health?

    Those who take high dose statins obtain benefit from less inflammation, but not because of cholesterol reduction?

    I'm not saying the above two statements are true, but it could be possible. It could also explain why statins, as a single treatment, usually don't work for most people, and why the Vytorin/Zetia/Torcetrapib trials failed so miserably.

    Or it could be that the reduction in LDL wasn't enough to matter, or that particle sizes for LDL/HDL wasn't taken into account, or some other factor? It appears that  right now, there isn't hard data that proves what causes heart disease exactly, but simply a lot of risk factors and disease markers instead.

  • Anonymous

    2008/4/15 1:52:00 |

    I never suggested that Cholesterol by itself caused heart disease. Clearly many things do, inflamation, CRP, Lp(a)... On the other hand to suppose that cholesterol has NOTHING to do with heart disease is foolish. Show me a cardiologist that believes cholesterol has nothing to do with heart disease and I'll show you a quack. It may not even be the main cause of heart disease in most people but the fact of the matter is reducing LDL lowers the the chance for heart attack in a good number of people. Have you ever heard of Dr. Agagston ? He of the South Beach Diet fame, a cardiologist in South Florida, who by the way the way of scoring calcium scans is named after. See what he thinks of statins and reducing cholesterol levels. and as Im sure you know it gets much more complicated than that when you get into particle size. Take a person who's scans keep going up because he has small LDL and nothing in Dr. Davis program has worked for him 9I am such a patient of the good Dr.s) The best you can do for such a person is lower his LDL as far as you can since its all going to be small particle anyway. I would also refer you to Dr. Greg Browns HATS Study for examples of lowering cholesterol and lowering heart disease or Dr. Davis' example that started this discussion. I apologise if I came off a bit sarcastic in my earlier comments I think this is an important issue to get all points of view on.

  • Anonymous

    2008/4/16 3:32:00 |

    Great thead.

    So what are you really saying about statins?  Is there value taking statins in combination with other treatments for men and women?

    How do you address the comments that states statins don't work?

    Thanks for your time.  Your comments are really appreciated.

  • Anonymous

    2008/4/16 18:14:00 |

    There is NO DOUBT that statins reduce the chances of a person having a heart attack, NONE. There is question as to what about the statins does that, is it lowering LDL, is it stablising plaque, is it reducing inflamation . . .? Or is it all of these ? And there is no doubt statins have side effects, some serious, but the fact that they reduce heart attacks, that argument has been settled.

  • J Michael Nicholls

    2008/4/16 19:26:00 |

    I will not go deeper into the science of atherosclerosis except to say that it has been known for several years now that cholesterol per se does not initiate atheroma, or plaque. You find cholesterol in the lesions but you also find calcium. We find cholesterol and calcium because it is available in the bloodstream. Cholesterol does not have a mind of its own, and it doesn’t one day decide to develop plaque by raising “the level”. Neither does calcium.

    We need cholesterol for many important processes in the body, and it is a part of almost all of our cell membranes. Mother’s milk is packed with it because the baby needs it. Eggs are full of the stuff “because it takes a hell of a lot of cholesterol to make a chicken”. The body has the level it needs at all times, and a higher level could indicate that something is wrong, i e, it is a marker, like someone said. Lowering of levels makes no sense at all.

    It is just dumb luck that the cholesterol lowering statins happen to be anti-inflammatory and therefore have some preventive effect, and may reverse plaque in some cases. The higher the dose the more anti-inflammatory effect, and reversal of atheroma. The higher the dose the bigger the lowering of the cholesterol level, because that is exactly how statins are designed to work. However, there is NO evidence in the scientific literature that the lowering of the cholesterol level has a protective effect, and I am very sorry if this upsets anyone’s religious beliefs. Dumb luck, as I said, the rest is coincidence and correspondence. Big Pharma will do its best to uphold the “religion” though, since it is so profitable. Levels will always be too high, and everybody should be statinated. Statins should be distributed in the drinking water, no less.

    So, why bother, the statins seems to work in a few cases? Well, statins are really poisonous substances, and there are many indications that they cause harm to the human body, particularly by the lowering of cholesterol levels. Side effects are plentiful and it is probable that we will witness statin induced cancers in large numbers in the near future.

    The point to be made here is that there are other and better methods to avoid atherosclerosis and to reverse plaque. Dr Davis is one of the leading proponents of such methods. I personally think it is interesting to se the results of the statin study presented here; I just wanted to stress the point of what statins really do. By all means, we should keep an eye our cholesterol levels. But many people having a hearth attack do not have high cholesterol. But did you know that 90% of them have diabetes or in some other way a pathological sugar metabolism? So what level is the more important?

    About the quacks, who don’t buy the cholesterol dogma, there are thousands of them. Some of them can be found at www.thincs.org. If you are interested in how the cholesterol religion was developed and how science was corrupted to that end, I can recommend Gary Taubes latest book Good Calories – Bad Calories.

    By the way, CRP is just another marker for hearth disease, but I wouldn’t be surprised if there will soon be talk about lowering the level Smile

  • Anonymous

    2008/4/18 1:13:00 |

    Well by your klogic there is no scientific proof the lowering inflamation is what cause stsatins to lower your risk of a herat attack, the only thing we do know is that ststins DO infact lower your risk, we just all keep guessing as to why. Well heres another piece to the puzzle: double blind study releasesed this week follow groups of people on statins or placebos and by a slight BUT significant margin the statin takers blood oressure was lowered ! So besides all the other things we think statins do we now KNOW they lower blood pressure. 2 ver5y interesting points for all of our paranoid readers 1. Not one of the study members recieving the statins in the 2 year period had to leave bececause of side effects and 2. this study was NOT paid for by the big bad scarry Drug companies, so there goes your default response.

  • buy jeans

    2010/11/3 16:55:07 |

    I am no supporter of drug companies, nor a defender of their policies and practices. But I do believe that their data can serve to teach us a few lessons. For instance, here is an (cherry-picked, to be sure) example of intracoronary ultrasound cross-sectional images before and after two years of rosuvastatin, 40 mg daily:

Flat tummy . . . or, Why your dietitian is fat

Flat tummy . . . or, Why your dietitian is fat

When I go to the hospital, I am continually amazed at some of the hospital staff: 5 ft 4 inch nurses weighing over 200 lbs, etc.

But what I find particularly bothersome are some (not all) hospital dietitans--presumably experts at the day-to-day of healthy eating--who waddle through the halls, easily 40, 50, or more pounds overweight. It is, to say the least, credibility-challenging for an obese dietitian to be providing nutritional advice to men or women recovering after bypass or stent while clearly not in command of nutritional health herself.

What's behind this perverse situation? How can a person charged to dispense "healthy" nutritional information clearly display such clear-cut evidence of poor nutrition?

How would you view a success coach dressed in rags? Or a reading coach who can barely read a sentence?

Easy: She follows her own advice.

Hospital dietitians are essentially forced to adhere to nutritional guidelines of "official" organizations, such as the American Heart Association and the USDA. There is some reason behind this. Imagine a rogue dietitian decides to advocate some crazy diet that yields dangerous effects, e.g., high-potassium diets in people with kidney disease. There is a role for oversite on the information any hospital staff member dispenses.

The problem, of course, doesn't lie with the dietitian, but with the organizations drafting the guidelines. For years, the mantra of hospital diets was "low-fat." More recently, this dated message has begun--only begun--to falter, but now replaced with the "healthy, whole grain" mantra. And that is the advice the hapless dietitian follows herself, unwittingly indulging in foods that make us fat.

Sadly, the "healthy, whole grain" message also contributes to heart disease via drop in HDL, increased triglycerides, a huge surge in small LDL, rise in blood sugar, increased resistance to insulin, tummy fat, and diabetes. Yes, the diet provided to survivors of heart attack increases risk.

The "healthy, whole grain" message also enjoys apparent "validation" through the enormous proliferation of commercial products cleverly disguised as healthy: Cheerios, Raisin Bran, whole grain bread, whole wheat pasta, etc. The "healthy, whole grain" message, while a health disaster, is undoubtedly a commercial success.

I'll bet that our fat dietitian friend enjoys a breakfast of healthy, whole grains in skim milk, followed by a lunch of low-fat chicken breast on two slices of whole grain bread, and ends her day with a healthy meal of whole wheat pasta. She then ascribes her continually climbing weight and size 16 figure to slow metabolism, lack of exercise, or the once-a-week piece of chocolate.

Wheat has no role in the Track Your Plaque program for coronary plaque control and reversal. In fact, my personal view is that wheat has no role in the human diet whatsoever.

More on this concept can be found at:

What's worse than sugar?

The Wheat-Deficiency Syndrome

Nutritional approaches: Large vs. Small LDL

Are you wheat-free?

Comments (19) -

  • Brock Cusick

    12/20/2008 5:26:00 PM |

    Dr. Davis,

    In your clinical practice, do you see good results from patients who continue to eat oats and/or brown rice as long as they cut out sugar, wheat and corn?  

    I ask because Dr. Weston Price's research found examples of cultures that used these grains (oats and rice) while continuing to exhibit signs of good health. He did not have access to modern diagnostics however, so perhaps he missed some indicators.

    Kind regards,

    Brock Cusick

  • baldsue

    12/20/2008 7:16:00 PM |

    Each time I contemplated seeking advice from a dietitian, I changed my mind after I saw the dietitian and decided I was doing well enough on my own.  Never felt like I could believe or trust dietary advice from someone whose BMI was obviously higher than my own.

    And I love my new flat stomach.

  • Anonymous

    12/20/2008 9:44:00 PM |

    My father had surgery 7 years ago at a well known Indianapolis hospital. During visitation I could not help but notice how overweight (some obese) the female receptionists and nurses were. They all looked to be in their early to mid 30s.I was speechless.

  • Anonymous

    12/21/2008 7:40:00 AM |

    that's what can happened even to a best-selling author of diet books http://tinyurl.com/8d4d4m

    in my country there's a saying "a shoemaker that walks on bare feet"

  • Anonymous

    12/21/2008 7:42:00 PM |


    Long-term consumption of a carbohydrate-restricted diet does not induce deleterious metabolic effects

  • Leniza

    12/22/2008 5:51:00 PM |

    I don't think that overweight dieticians (and nurses, and doctors)even follow their own advice. Not that that advice isn't garbage anyway, but I doubt that whole grains and lots of fruit and lean meats make up the bulk of their diets. It's probably more the case that these people aren't following the rules they give their patients (not that the rules would work, anyway). "Knowing" something and choosing to do it are two different things. I completely agree with you on sugar and wheat, but that doesn't mean I'm not going to indulge without guilt during the holidays (I don't have any health problems, though.)

    It's like with smoking. People KNOW it's bad for them, but they still do it. I know several doctors who tell their patients to quit smoking, but who smoke like chimneys themselves. I used to work with a PULMONARY PATHOLOGIST who was a chain smoker.

  • Jean-Luc Boissonneault

    12/22/2008 7:40:00 PM |

    Thank you, I'm so glad you said this! This makes me sick! I say practice what you preach or don't preach at all. At my personal training centre, my trainers are all in good shape. I tell them it's like a hopelessman giving financial advice.

  • Anonymous

    12/23/2008 3:27:00 PM |

    Dr. Davis, thought you'd find this interesting:


    Journal reference:

       1. Piconi et al. Treatment of periodontal disease results in improvements in endothelial dysfunction and reduction of the carotid intima-media thickness.

    The FASEB Journal, 2008; DOI: 10.1096/fj.08-119578

  • Ricardo Carvalho

    12/29/2008 1:16:00 PM |

    Dear Dr. Davis, I suppose the WHO wants everyone to be fat, don't they?! Nutritionists simply follow these poor recommendations. Who's fault? -> http://www.euro.who.int/nutrition/20030321_1

  • extropolitca

    12/29/2008 11:03:00 PM |

    WHO is right in his recommendation.
    Right with the mean of the people living on Earth.
    I'm italian, living in Italy.
    Mediterranean diet (the real deal) is very good if you are a peasant in agricultural job doing hard work (4.000 Kcal/day). Than you can eat your pound or two a day of bread plus salami, cheese and olive oil and fruits, be full, lean and healthy.

    You move to city, start to work in an office, cut all to 2.000 kCal/day proportionally and you find yourself hungry, gaining fat and lacking minerals and vitamins with the same diet.

  • Juhana Harju

    1/1/2009 1:22:00 PM |

    This is a naughty blog entry... but I agree. Smile I have been pondering the same question.

    While I approve the use of whole grains, I agree with Extropolitcan's view that reduced energy expenditure should lead to changes in diet. We should probably use more nutrient dense foods. I would also like to promote the idea of moderation, which is really a beautiful and positive idea, not appreciated enough in our Western culture.

    Wishing everyone a Happy New Year,

    Juhana Harju
    BMI 22

  • Anonymous

    11/25/2009 5:35:44 PM |

    I've seen more fat doctors than fat dietitians. I'm a dietitian and I'm at a perfect body weight, AND I follow my own advice, which is to eat in moderation. This is an extremely unfair stereotype to make. Between doctors and nurses thinking they know all about nutrition with minimal education in it, and patients asking for advice and then telling you that you're wrong right to your face, it's no wonder clinical nutrition has such a high burnout rate and low rate of job satisfaction.

  • Anonymous

    5/13/2010 1:52:39 AM |

    I'm a fat dietitian, and we fat dietitians know how much we are hated.

    I find it interesting that the topic of "dietitians that follow their own advice" had to be written with such contempt. Consider the message your readers came away with...many commented on their contempt of fat people rather than grasping the diet advice you are promoting. "A naughty post" BMI 22 wrote. Why naughty? Because ridiculing someone for being fat is still acceptable behavior in this part of the world, even though we know we should not "throw stones". Consider promoting your message without inciting the contempt of others.

    In addition, consider how being fat can't be hidden, the way other characteristics can. For example, what physical characteristics are required of a realtor, plumber, grocery clerk, insurance salesperson? It might not matter if they were fat since they are not dispensing "health" advice, but consider all of the unseen ways they might deviate from the norm.

  • Anonymous

    7/6/2010 6:47:04 PM |

    I'm a dietitian as well, and although not "fat", I find it challenging to maintain weight. This not because of any "bad" advice I'm giving, it's just the way life is sometimes.

    That said---I hope that someday you are publicly ridiculed for something you struggle with. I hope you are ridiculed for your imperfections, which I'm sure you have. Dietitians aren't any more perfect than anyone else. Just because we understand the physiology behind things doesn't mean that life is any easier for us. Maybe the "fat dietitian" in the hallway has things going on in her life that you don't know about, and you should keep your "fat" mouth shut about it.

  • buy jeans

    11/4/2010 6:34:29 PM |

    Sadly, the "healthy, whole grain" message also contributes to heart disease via drop in HDL, increased triglycerides, a huge surge in small LDL, rise in blood sugar, increased resistance to insulin, tummy fat, and diabetes. Yes, the diet provided to survivors of heart attack increases risk.

  • Michael Scott

    10/1/2011 2:31:15 AM |

    I'm 69 and have been on Atkins, level one, for a little more than eleven years.  I now consider myself a "former" overeater because as long as I remain below twenty grams of carbs per day, I'm totally in control of my eating.  Even after eleven years I understand that my chances of ever being able  to eat more than 20 grams of carbs per day will never happen!  Like an alcoholic, whenever I reach my "carb limit" I have to stop at that point.  I can't eat even a single bite of any grain products without "falling off the wagon".  A single bite of bread or pizza crust and I become an alcoholic with food!  I'm just amazed that more dietitians  are not overweight eating grains.  Anyone who can eat grains and still remain under 400 pounds has my admiration.

    Mike Scott

  • Dr. William Davis

    10/1/2011 1:45:47 PM |

    Hi, Mike--

    Your experience is something like my personal experience, though my carbohydrate cutoff is around 30 grams per day. Some of us are just not equipped to handle the high insulin requirement, while others can get away with much more. Find your individual path and stick to it!

  • Michael Scott

    10/1/2011 3:21:52 PM |

    This information is for the dietitian who suggested eating in moderation.  Is this the same advice we give to an alcoholic?  Do we tell them to drink in moderation?   About the only advice an over eater receives from a doctor or dietitian is:  Starve yourself for the rest of your life and don't forget to kill yourself exercising!  Now we all know that these may not be their exact words, but trust me that is exactly what an over eater hears just before going into “full panic mode”.  When my eating was “totally out of control”, I had as much chance of stopping at one slice of bread as a “down and out” alcoholic has of stopping after one drink!  Until we all understand this, there is almost no long term hope for a “fat” person.  We do not suggest that an alcoholic drink in moderation for a very good reason.  How can we advise someone with a major eating disorder to eat the very foods they are addicted too.  Had I not given up whole grains, fruit and any high carb vegetables, I would now be 400 pounds.  I learned this thanks to Dr. Atkins.  If not for him I wouldn't be here now.  How many 400 pound, 69 year old men do you know?  Moderation of grains/alcohol will never work.  

    Michael Scott (again)

  • Dr. William Davis

    10/2/2011 2:44:08 PM |

    Well said, Michael!

    You make a crucial point: How many 400 pound, 69 year old men do you know?